Aggressive blood conservation in coronary artery surgery: impact on patient care

Data on 100 consecutive non-emergency coronary artery bypass (CABG) patients were analyzed retrospectively. Sixty-nine patients received no homologous blood (Group I). Thirty-one patients received a total of 118 units of blood products averaging 2.23 units of red cells (Group II). The average red cell transfusion rate for all patients was 0.7 units per patient. The median age for Group I was 61 and Group II was 68 years (p less than 0.05). The average number of grafts was the same for both (3 per patient) with 75% of Group I and 58% of Group II receiving internal mammary artery (IMA) grafts (p less than 0.05). Twelve of the Group II patients who received intraoperative transfusions on cardiopulmonary bypass to maintain adequate hemoglobin levels were older and had lower admission hematocrits: 36 +/- 0.8% compared to 41 +/- 0.5% for all other patients (p less than 0.05). Average postoperative blood loss was 889 +/- 38 ml for Group I and 1077 +/- 104 ml for Group II (p less than 0.05). Increased hemorrhage was correlated with bypass time and IMA use but not with preoperative heparin administration, pre-existing risk factors (diabetes, hypertension, etc.), bleeding time, post-bypass clotting time, age or number of grafts. Two patients in Group II and none in Group I required exploration for excessive postoperative hemorrhage. Mortality rate was 2% (both in Group II, neither transfusion related). Discharge hematocrits were the same for all at 29.4 +/- 0.4%. Among anemia-related postoperative symptoms, only sinus tachycardia was significantly higher in Group I (20%) compared to Group II (6.5%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Favorable results of coronary artery bypass grafting in patients older than 75 years

There is controversy whether the short-term and long-term results of coronary artery bypass grafting in elderly patients justify performing the procedure. Between January 1977 and December 1986, 4580 patients underwent coronary artery bypass grafting, of whom 222 (4.9%) were 75 years old or older (mean 77 years). There were 143 men and 79 women and 139 (63%) were in New York Heart Association class IV. One hundred forty-six patients (66%) had had at least one preoperative myocardial infarction. Myocardial revascularization was performed under emergency conditions in 17 patients (18%). The mammary artery was used in 43%, 96% of the patients received two or more grafts. The mean number of bypass grafts was 3.1 per patient. The overall hospital mortality rate was 10.8% (24/222), 3.6% for elective procedures, 14.9% in urgent cases, and 35% in emergencies. In contrast, the overall early mortality rate was 3.1% in 4358 patients less than 75 years old. Complications occurred in 83 patients (37%). Of the patients discharged from the hospital, 198 were followed up for a mean of 48 months (1 to 130). Actuarial probability of survival was 75% at 48 months. Postoperatively 70% were in New York Heart Association class I or II and only 21% were rehospitalized for cardiac problems. During the follow-up period 77% of the patients were free from angina, and of those experiencing angina the mean time from operation to the first episode was 75 months. Although elderly patients have a somewhat increased operative mortality rate, particularly if operated on urgently or emergently, long-term survival and freedom from angina are excellent and justify continued performance of coronary bypass grafting in selected patients over 75 years of age.     

Prognosis of acute ischemia of the lower limbs in patients over 80 years of age. A prospective study

To demonstrate the importance of age in the prognosis of acute lower limb ischemia, a prospective study was performed in 137 patients over 24 months. Group I contained 75 patients aged under 80 years and group II 62 patients aged over 80 years. Risk factors and previous history were equally distributed in the two groups. The level of arterial blockage and the treatment were comparable in the two groups. Mortality was higher in group II than in group I (p less than 0.01). In both groups deaths were principally due to cardiac causes and a revascularisation syndrome. Amputation at thigh level was more common in group II (p less than 0.01). Mortality was higher in group II for combined thigh level amputation and cardiac or coronary insufficiency (p less than 0.05). This study demonstrated that, in terms of prognosis of acute lower limb ischemia, the critical threshold is 80 years.     

Esophageal carcinoma in young patients

The clinicopathological features of esophageal carcinoma were examined from the viewpoint of age differences in a study of 364 consecutively treated patients. The three groups studied were: group I, aged less than 49 years; group II, aged between 50 and 69 years; and group III, aged more than 70 years. There were no significant differences among the three groups with regard to sex ratio, site and length of the lesion, gross types, histological grade, depth of tumor invasion, vessel permeation, lymph node metastasis, TNM classification, incidence of incomplete resection, or crude actuarial 5-year survival curves. The malignant potentiality of the esophageal carcinoma in young patients did not differ from that in older patients in terms of deoxyribonucleic acid distribution pattern. The only difference clearly evident between young and older patients was the number of hospital deaths due to complications: That of the young patients was significantly lower than that of the older patients (p less than 0.05). Esophageal carcinoma in persons aged less than 50 years appeared to behave biologically like the same neoplasm in older people, whereas gastric and colorectal carcinomas behave differently in various age groups.     

Influence of pancreas and kidney transplant function on recipient survival

The aim of this study was to evaluate long-term survival after simultaneous pancreas and kidney (SPK) transplantation in relation to function of both grafts. Among 67 recipients who received SPK transplants between 1988 and 2004, 35 had follow-up longer than 18 months, and were divided into: group I (n = 20), recipients with good function of both grafts; group II (n = 7), patients who had lost transplanted pancreas but had still good kidney graft function; group III (n = 8), patients who had lost both grafts. Comparison of survival rates and analysis of the reason of mortality among groups was performed. The cumulative survival rate was significantly higher in group I than in group III (after 3, 5, 10 years: 100%, 100%, 80% vs 75%, 50%, 37%, respectively). Cumulative survival rate for group II after 3, 5, 10 years was 100%, 100%, 33%, respectively. There were no significant differences in survival rates between groups I and II and between groups II and III. In group I deaths for cardiovascular event and for leukemia were noted. In group II deaths due to cardiovascular event and sepsis were observed. In group III all patients died due to cardiovascular events and the mean time from loss of pancreas and kidney graft function to death was: 75 +/- 51 months (range from 19 to 142), and 49 +/- 26 months (range 19 to 99), respectively. Good pancreas and kidney graft functions prevent death due to cardiovascular event.     

Repair of complete atrioventricular septal defects in patients weighing less than 5 kg

BACKGROUND: The aim of this study was to evaluate the impact of weight less than 5 kg at operation on mortality and morbidity in patients with atrioventricular septal defect (AVSDc) undergoing total correction. METHODS: Between January 1990 and December 2002, 190 consecutive patients with AVSDc underwent total biventricular correction. They were divided into two groups: group I (n = 64 patients weighing < 5 kg) and group II (n = 126 patients weighing > 5 kg). Associated major cardiac malformations were found in 49 (25.8%) patients. Associated left atrioventricular valve (LAVV) malformations were found in 35 (18.4%) patients. The mean follow-up time was 4.1 +/- 2.9 years (range 2 months-10.7 years). RESULTS: The in-hospital mortality in group I was 7.8% (5 patients) versus 8.7% (11 patients) in group II (p = 0.95). Major associated cardiac malformations (p < 0.001) and pulmonary hypertension (p = 0.006) were found to be strong predictors for poor postoperative survival. At discharge the mean LAVVR grade in group I was 1.45 +/- 1.2 versus 1.2 +/- 1 in group II (p = 0.13). The actuarial overall survival rates at 1, 3, 5, and 7 years were 96.5%, 92.5%, 91.5%, and 89% respectively and the actuarial overall reoperation free survival rates at 1, 3, 5, and 7 years were 95%, 87%, 84%, and 73%. Twenty-three patients underwent reoperation due to severe left atrioventricular valve regurgitation (LAVVR). Strong predictors for overall reoperation free survival were the operation year before 1995 (p < 0.001), postoperative LAVVR greater than or equal to 2 (p = 0.006), major associated cardiac malformations (p = 0.00034), associated LAVV malformations (p = 0.0044), and non or partial LAVV cleft closure (p = 0.012). The actuarial survival rates between patients weighing less than 5 kg versus patients weighing more than 5 kg were similar (p = 0.51); instead the overall reoperation free survival was significantly lower in patients weighing less than 5 kg (p = 0.022) according to the log-rank test. Weight less than 5 kg (p = 0.023, beta = -0.6) was one of the predictors for reoperation due to severe LAVVR in this series. CONCLUSIONS: We may conclude that in the current era repair of AVSDc can be carried out successfully in patients less than 5 kg, however, weight less than 5 kg at initial complete repair seems to be a predictor for late reoperation due to LAVVR. Suture separation at the cleft site or between the leaflets of the newly created mitral valve and the patch remain the main causes of postoperative LAVVR in patients weighing less than 5 kg.     

Liver transplantation in patients over sixty years of age.

BACKGROUND: Although some centers have reported very good patient and graft survival in liver allograft recipients, reports from both North America (United Network of Organ Sharing) and Europe (European Liver Transplantation Registry) have failed to confirm this. AIM: We have reviewed our experience of liver transplantation in older recipients and compared their clinical outcome to a younger group. METHODS: Retrospective analyses were conducted on 875 consecutive adult patients undergoing liver transplantation for chronic liver disease, between 1990 and 1999. Group I consisted of patients under 60 years of age (n=701; 80.2%) and group II of patients over 60 years (n=174; 19.8%). RESULTS: The proportion of older patients transplanted increased from 10.15% between 1990-1991 to 20.85% (1997-1999). Actuarial graft survival at 1, 3, and 5 years was 78%, 74%, and 69% and 78%, 73%, and 66% for groups I and II, respectively (P=0.49). The overall actuarial patient survival tended to be better in the younger group (1-, 3-, and 5-year survival of 83%, 79%, and 76% for group I and 81%, 75%, and 69% for group II (P=0.07). Crude mortality probability shows a stable trend until 45 years, a gradual increase in mortality between 45 and 60 years, and then the risk of death is accelerated. The same analysis shows the risk of death is between 1.5 and 2 times greater in Child C patients; this is greater in patients aged more than 66 years. CONCLUSION: There is no statistically significant difference in patient or graft survival in patients aged over 60 compared to younger recipients. However, when age is assessed as a continuous variable, an adverse effect of older age is seen on outcome and this effect is more marked in sicker patients.     

Effect of prior cardiac surgery on survival after heart transplantation

We conducted a retrospective analysis of 182 adult orthotopic heart transplant patients who underwent operations at our institution between July 1982 and October 1987 to determine whether prior cardiac operation affects survival. Group I included the 72 patients (39.6%) who had undergone a previous cardiac operation or operations and group II, the 110 (60.4%) who had not. The mean age of the patients in group I was 52.1 +/- 8.1 years and in group II, 46.1 +/- 10.2 years (p less than 0.01). The incidence of ischemic heart disease was 86.1% in group I and 29.1% in group II (p less than 0.01). All patients received cyclosporine-based immunosuppression. More patients in group I than in group II required reoperation for bleeding after transplantation: 18 (25.0%) versus 9 (8.2%) (p less than 0.01). The actuarial 1-year and 3-year survival rates were 77.6% and 66.5%, respectively, for group I and 77.1% and 66.3%, respectively, for group II. Because both groups had similar survival rates, we believe that prior cardiac operation in heart transplant recipients does not compromise long-term survival.     

Renal transplantation in children with emphasis on young patients

We report the results of 41 consecutive renal transplantations performed on 39 children (median age 2.7 years). Twenty-six recipients were less than 5 years old. Twenty-one recipients (13 under the age of 5 years) received cadaver (CAD) grafts. All grafts except 2 were from adult donors and were placed extraperitoneally. Patients were on triple immunosuppression (cyclosporine plus azathioprine plus methylprednisolone). Mean followup time was 2.3 years. No vascular and only one ureteral complication was seen. Acute tubular necrosis occurred in 3 patients (7.3%). No grafts were lost due to acute rejection. Three-year patient survival and 1-year graft survival were 100%. The overall 3-year actuarial graft survival was 86%. Three-year survival of grafts from living-related donors (LRD) was 92% and that of CAD grafts 75%. In recipients younger than 5 years, 3-year LRD graft survival was 89% and CAD graft survival 73%. No significant differences in graft survival between recipients of different age groups or between LRD and CAD grafts were found. We conclude that results of renal transplantation in children under 5 years of age are comparable to those of older children, even using CAD grafts, when adult donors and triple immunosuppression are used.     

Postoperative somnolence in patients after carotid endarterectomy

Eighty-one patients undergoing carotid endarterectomy were divided into two groups based on the degree of stenosis of the carotid artery. Group I, 37 patients, was defined as having severe carotid stenosis (greater than 70%). Group II, 44 patients, was defined as having mild (less than 40%) or moderate (40% to 70%) carotid artery stenosis. Both groups were evaluated for neurologic and psychologic changes in the postoperative period. Prospective analysis demonstrated no significant differences between groups I and II in the areas of cardiac disease, history of preoperative stroke, preoperative and postoperative hypertension, diabetes, or postoperative computed tomography changes. Group II had a significantly higher percentage of carotid artery ulceration (p less than 0.01). Postoperative analysis revealed 34 group I patients had 6 to 8 weeks of lethargy versus two group II patients (p less than 0.01). Eleven group I patients had headaches for the first week postoperatively versus three patients in group II (p less than 0.05). Four group I patients had paranoid ideation, and another four patients had clinical depression, but not one patient in group II (p less than 0.01) had these psychiatric disturbances. These data suggest that significant, reversible neurologic and psychologic changes can occur because of reperfusion after relief of severe stenosis of the carotid artery.     

Long-term (5 to 12 years) serial studies of internal mammary artery and saphenous vein coronary bypass grafts

Serial arteriograms were obtained in 501 patients after coronary bypass grafting. Study I within 5 years of operation (mean interval 15 months) and Study II more than 5 years after (mean interval 88 months, range 60 to 147 months). One hundred patients received both internal mammary artery and saphenous vein grafts: 37, mammary artery grafts only, and 364, vein grafts only. In Study I, 645 (82%) of 786 vein grafts were patent, 42 (5%) stenotic or irregular, and 99 (13%) occluded. Of 140 mammary artery grafts, 136 (97%) were patent, two (2%) stenotic, and two (2%) occluded. Of the 645 vein grafts patent in Study I, 357 (55%) remained patent in Study II, 119 (18%) were stenotic or irregular, and 169 (26%) were occluded. Of 136 mammary artery grafts patent in Study I, 130 (96%) were unchanged, one was stenotic, and five (4%) were occluded in Study II. Early vein graft patency was influenced by the coronary artery grafted and by angina. Progression of vein grafts patent at Study I to stenosis or occlusion at Study II was associated with increasing postoperative interval (p less than 0.00001), interval myocardial infarction (p less than 0.001), angina (p less than 0.001), diabetes (p less than 0.004), hypercholesterolemia (p less than 0.006), and hypertriglyceridemia (p less than 0.02); it was not influenced by the coronary artery grafted. Within 5 years of operation, mammary artery graft patency exceeded vein graft patency. Between 5 and 12 years after operation, the attrition rate of vein grafts greatly exceeded that of mammary artery grafts (p less than 0.0001).     

Reoperative coronary surgery. Comparative analysis of 6591 patients undergoing primary bypass and 508 patients undergoing reoperative coronary artery bypass

During an 18-year period a consecutive series of 6591 patients underwent primary coronary bypass grafting and 508 patients underwent reoperative bypass. The mean patient age for the reoperative group was identical to that of the primary group, 59.8 years, but the mean age at initial operation for the reoperative group was 55.2 years. Mammary grafts were done at initial operation in 59% of patients who have had one operation versus only 46% of patients who subsequently required reoperation (p less than 0.001). The overall operative mortality rate was 2.0% (134/6591) for primary coronary bypass versus 6.9% (35/508) for reoperations (p less than 0.001). Patients with a reoperative interval of 1 to 10 years had a 6.0% (18/312) mortality rate, compared with 17.6% (13/74) for those in whom the interval between operations was greater than 10 years (p less than 0.01). Ventricular arrhythmias, excessive bleeding, prolonged ventilatory support, intraaortic balloon pump insertion (all p less than 0.05), and perioperative myocardial infarction (p less than 0.001) were all more prevalent after reoperations. Including perioperative mortality, the actuarial survival rate at 5 years was 80% for reoperations versus 90% for primary operations. The corresponding figures at 10 years were 65% and 75%. The probability of undergoing reoperation within 5 and 10 years was 0.034 +/- 0.003 and 0.055 +/- 0.005, respectively. Ten years postoperatively, 36% of patients having the initial operation had recurrent angina whereas 58% of the reoperative group had significant recurrent angina. Ten years after reoperation, 30% of operative survivors were free of heart-related morbidity and mortality compared with 50% of patients having a primary operation. Univariate analysis of factors increasing the probability of reoperation include the absence of a mammary graft and younger age at operation. Patients undergoing a second bypass operation represent a substantially higher risk subgroup than patients undergoing initial operation in terms of perioperative morbidity, mortality, decreased long-term survival, and decreased relief of recurrent cardiac morbidity.     

Carotid endarterectomy in patients aged 75 and over: early results and late outcome.

BACKGROUND: The mean age of patients in the European Carotid Surgery Trial with greater than 70% stenosis was 62 years. With changing demographics older patients are increasingly being referred for carotid endarterectomy (CEA). OBJECTIVES: To assess the complications and survival (stroke-free and overall) of patients over the age of 75 undergoing CEA. METHODS: Analysis of a database, clinical records and cause of death of patients undergoing CEA in a single regional unit over a 7 year period (1/4/1993 until 1/4/2000), with follow-up to April 2002. The rates of further neurological events were obtained from the Scottish Morbidity Record 1 (SMR 1) of hospital discharges. Patients referred from outside the region were excluded. Differences between groups were assessed by the Chi-squared test, with Yates correction and log-rank tests. RESULTS: Of the 235 patients undergoing CEAs, 55 (23%) were 75 years or older. The post-operative neurological complication rate was 1.7% in the under 75's and 5.4% in the older group (p < 0.05). The 30 day mortality was 1.1% (two patients) and 1.8% (one patient) respectively. The Kaplan-Meier estimated survival for the under 75's and older were 93 and 75% at 3 years and 80 and 59% at 5 years respectively (p < 0.001). The Kaplan-Meier estimated neurological event-free 5 year survival for the under 75's and older patients were 96 and 82% respectively (p < 0.001). CONCLUSION: CEA in patients aged 75 years and over is associated with a significantly increased risk of stroke and death. CEA may not benefit elderly patients with a reduced life expectancy.     

Clinical outcome of single versus sequential grafts in coronary bypass operations at ten years' follow-up

To evaluate the long-term outcome of the sequential aorta-coronary bypass grafting technique, we compared the results in 234 patients with single venous grafts (group I) with those of 234 patients with predominantly sequential grafts (group II). All were symptomatic for angina pectoris before operation and had either three-vessel or left main stem coronary artery disease. Operations were performed from March 1975 to June 1980. The mean follow-up period was 10.5 years (minimum 8.5; maximum 13.6). The perioperative mortality rate in group I was 3% and in group II, 1% (not significant). The survival probability at 5 years after operation for group I was 90% +/- 2% and for group II, 88% +/- 2%; at 10 years, 71% +/- 3% and 72% +/- 3%, respectively. Multivariate analysis elicited no risk difference related to graft type: group II versus group I hazard ratio, 0.82; 95% confidence interval 0.58 to 1.16 (not significant). Regarding depressed left ventricular function versus normal function, an increased risk was observed: 1.9 (95% confidence interval 1.35 to 2.75), as was the case for advanced age: 60 years or more versus less than 60 years, 1.6 (1.1 to 3.5). Thus the sequential venous grafting technique seems to have the same 10-year results as single venous grafts.     

Our experience in liver transplantation in patients over 65 yr of age

Abstract:  Objectives: The aim of this study was to analyze short- and long-term results of liver transplantation (LT) in patients over 65 yr. Material and methods: Between 1996 and 2004, 386 patients underwent 415 LT at our center. The main indication for LT was post-necrotic cirrhosis in 59%, followed by hepatocellular carcinoma (HCC) over cirrhosis in 33%. Half of the patients (53%) were hepatitis C virus (HCV) +. Overall, 72 patients were >65 yr of age. Actuarial survival, causes of mortality and postoperative complications were compared between groups: patients under and over 65 yr. Risk factors for poor outcome in patients over 65 yr were also analyzed. Results: The older group had more patients at Child A stage, more HCC as an indication for LT and more HCV (+) patients, p < 0.05. No differences were observed in donor and surgery characteristics, except for lower multi-transfusion and higher incidence of grafts with steatosis in the older group (p < 0.05). Actuarial survival at one, three, five and 10 yr was 82%, 75%, 72%, and 70% for the <65 yr group vs. 77%, 66%, 55%, and 55% for the >65 yr group (p = 0.03). Main causes of mortality in patients >65 yr were recurrence of underlying disease and medical causes. In the older age group, fewer infections (p = ns) and rejections (p = 0.017) occurred in the postoperative period. Risk factor for poor outcome in the group of patients over 65 yr in multivariate analyses was pre-LT renal insufficiency (odds ratio 3.5, p = 0.002, 95% confidence interval 1.58–7.82). Conclusion: Results in patients >65 yr are comparable to those <65 yr if older LT candidates are carefully selected. Overimmunosuppression should be avoided in older candidates, as its effects could worsen the pre-existing diseases common in elderly patients.     

Surgical treatment for esophageal cancer in elderly patients over 75 years of age

We performed 127 esophageal resections for the esophageal cancer patient from December 1995 to September 2001. It was separated to under 70 years old patients group (group I), 71-74 years old patients group (group II), and over 75 years old patients group (group III). RESULTS: Postoperative complication was occurred in 53 cases (41.7%) within all of 127 esophageal resected cases. It was 33.7% in group I, 53.6% in group II, 62.5% in group III. Four years survival rate of each group is 38.3% in group I, 44.6% in group II, 31.3% in group III. It is significantly better in group II rather than in group III. Operative death rate is 12.5% (2 cases) in group III, 7.1% (2 cases) in group II, 3.6% (3 cases) in group I, and it is gradually higher and higher by patient's age. CONCLUSIONS: (1) In the esophageal cancer patient over 75 years old, postoperative complication rate is higher than under 74 years old patients, and prognosis is significantly poor rather than in 70-74 years old patients group. (2) In the esophageal cancer patient over 75 years old, we considered it is good indication of esophagectomy for stage I and stage II patient without preoperative complication, however, there are no operative indication for stage III and stage IV patient.     

Flow waveform analysis and long-term results of autogenous saphenous vein and polytetrafluoroethylene grafts in 140 arterial reconstructions of the lower limbs

In previous work we have found that the outcome of grafts in the lower limbs correlated with the flow waveform pattern of the artery. We have retrospectively reviewed 140 femoro-popliteal bypass operations involving the use of 75 saphenous vein grafts and 65 polytetrafluoroethylene (PTFE) grafts. For grafts with type 0 or I flow waveform pattern the patency at 4 years (56%) was superior to grafts with the type II, III or IV flow waveform (35%) patterns (P less than 0.05). For saphenous vein grafts with type 0 or I flow, the patency rate was 78% at 3 years and 69% at 5 and 8 years. In contrast with type II, III or IV flow the patency rate was 52% at 3 years, 48% at 5 years and 34% at 8 years, with a statistical significance at 4 years (P less than 0.05). PTFE grafts with type 0 or I flow showed a tendency toward an increased patency which was not significant in comparison with the grafts with type II, III or IV flow (P = 0.12). Saphenous vein grafts with type II flow patterns had an increased occlusive rate in the first year whereas PTFE grafts had the same tendency within 2 years. In both types of graft, early occlusions within a month of operation were encountered in grafts with a type III or IV flow waveform pattern. These results indicate that the fate of the reconstructed arteries of the lower limb could be predicted by flow waveform analysis, and a careful and serial postoperative evaluation of the graft should be made, particularly those with type II, III or IV flow waveform patterns.     

Prevalence of Helicobacter pylori in patients with end-stage renal failure and renal transplant recipients.

The prevalence of Helicobacter pylori was determined using an ELISA technique for IgG antibodies to H. pylori in 76 patients with end-stage renal failure who were receiving regular haemodialysis and 202 patients with functioning renal transplants. Twenty-seven (34%) of the haemodialysis group and 58 (29%) of the transplant group were positive for H. pylori IgG antibodies, and the prevalence did not differ significantly from that in 247 age-matched healthy controls. In the haemodialysis group, patients positive for H. pylori were older, median age 60 years (range 22-73), compared to those patients without H. pylori antibodies, median age 52 years (range 22-75), p less than 0.05, more suffered from dyspeptic symptoms, 35 vs. 10% (p less than 0.01), yet fewer had been prescribed aluminium-containing antacids, 38 vs. 78% (p less than 0.01). In the transplanted group, those positive for H. pylori were more symptomatic for dyspepsia, 30 vs. 11% (p less than 0.01), and had lower serum creatinine values, 136 +/- 10 mumol/l (mean +/- SEM) vs. 172 +/- 12 mumol/l (p less than 0.05), compared to those without H. pylori antibodies. Almost all the transplant patients with H. pylori antibodies were taking steroids (98%) compared to 84% of those without antibodies (p less than 0.05). The prevalence of antibodies to H. pylori in this study was increased in symptomatic dyspeptic subjects and reduced in those patients prescribed aluminium-containing phosphate binders.     

Target vessel revascularization without cardiopulmonary bypass in elderly high-risk patients

BACKGROUND: Coronary artery bypass grafting in patients over 75 years is associated with high operative risk. Target vessel revascularization without cardiopulmonary bypass is a promising option for highly selected, older patients. However, the outcome remains uncertain. METHODS: We investigated 44 patients over 75 years, matched for preoperative risk and left ventricular function, who underwent coronary artery bypass grafting either with or without cardiopulmonary bypass (CPB). We analyzed patients characteristics, Parsonnet score, EuroSCORE, short as well as midterm outcome and quality of life (freedom from recurrence of angina, anti-anginal therapy, sf36 test). RESULTS: Perioperative mortality was higher in the patient group operated with CPB (15.9) as compared to patients operated without CPB (4.5%, p = 0.0226). Patients operated with cardiopulmonary bypass received more grafts (3.1 +/- 0.1) than patients operated without cardiopulmonary bypass (1.6 +/- 0.1, p = 0.0001) and and were more likely to undergo complete revascularization (with CPB 100%, without CPB 63.6%, p = 0.0010). Perioperative complications were more frequent and midterm survival was worse in the patient group operated with CPB (log rank p = 0.0228). Quality of life was comparable in both groups. CONCLUSIONS: The concept of incomplete target vessel revascularization of the culprit lesion seems to be a promising option for selected high-risk patients, predominantly due to lower perioperative mortality.     

Nocturnal urinary protein excretion rates in patients with sleep apnea

We observed nocturnal urinary protein excretion to be 16.2 +/- 5.5 micrograms/min (mean +/- SE) in 9 healthy control subjects (group I), 29.3 +/- 9.5 micrograms/min in 12 obese patients suspected to have obstructive sleep apnea syndrome (OSAS) but with negative polysomnographic studies (group II), and 94.0 +/- 31.8 micrograms/min in 14 patients with documented OSAS (group III) (II vs. I, NS; III vs. I, p less than 0.05; III vs. II, p less than 0.05). The frequency of abnormal proteinuria, defined as protein excretion greater than the highest rate observed in group I (46 micrograms/min), was 14% in group II and 64% in group III (p less than 0.05). There were no significant differences in age, body weight, body surface area, blood pressure, or indices of sleep apnea between OSAS patients with and without proteinuria. Although the mechanism is unclear, this study shows that nocturnal protein excretion rates are commonly elevated in patients with OSAS.